minimally invasive esophagectomy dmitry oleynikov m.d. associate professor of surgery joseph and...
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Minimally Invasive Esophagectomy
Dmitry Oleynikov M.D.Associate Professor of Surgery
Joseph and Richard Still Faculty Fellow in MedicineDirector of Minimally Invasive And
Computer Assisted Surgery
University Of Nebraska School Of Medicine
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0
5,000
10,000
15,000
1940 1970 1998 2001
adeno CA
squam CA
total cases
Esophageal Cancer
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Staging / determining resectability:
• Laparoscopic/ thoracoscopic staging is accurate– 94% correlation with operative pathology*
• It is the best method, short of laparotomy, to determine resectability– 30% (6/20) positive nodes in imaging negative
patients*
* Krasna; 1995, 1998
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Node dissection
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Endoscopic diagnosisBarretts adeno CA
EUS + PET/CT
Stage I Stage II Stage IIIA Stage IIIB Stage IV and Barretts HGD
Chemo/rador
palliation
IntraoperativeStaging/
Laparoscopic resection
Laparoscopic stagingU/S, node dissection,Left gastric divisionFeeding jejunostomy
Stage II, IIIA Stage IIIA, IIIB
StageIV
Laparoscopic Or
Open resection
NeoadjuvantChemo/radiation
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Endoscopic esophagectomy: which approach?
• Totally Endoscopic techniques:
– laparoscopic transhiatal esophagectomy (DePaula, Swanstrom, Sadanaga, Jagot, Yahata)
–Laparoscopic/thoracoscopic technique (Cuscieri, Luketich, Dellemagne, Watson)
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Survival after open esophagectomy
0
10
20
30
40
50
60
70
80
90
100
1st Yr 2nd Yr 3d Yr 4th Y 5th YR
Stage IStage IIStage IIIStage IV
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Background:esophagectomy patients
• Perioperative complications in 58% *• Perioperative mortality is 4% *• Ave length of hospital stay 13.7 days**• 31% of patients require post hospital care**
* Finley, AM J Surg, 1995
** OR state tumor registry, 1998
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Expected advantages:
• Accurate staging• Minimally invasive determination of
resectability• Decreased tissue trauma
– less pain– less pulmonary compromise
• Decreased need for critical care / hospital care
® A more rapid return to normal life
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Theoretical advantages:
• Better node dissection• Less tumor manipulation• Preservation of host immune response
– lower blood loss– quicker enteral feedings– less inflammatory mediator release
• Quicker application of adjuvant therapy• Psychological impact
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Alternative Therapies:
• Chemo / radiation• Photoablation• Cryotherapy• Endoscopic Mucosal Stripping• Full thickness endoscopic resection• Laparoscopic / thoracoscopic
esophagectomy
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Survival after open esophagectomy
“Results of 100 radical en bloc resections for adenocarcinoma” Hagen JA et al. Ann Surg 2001
• A radical lymphadnectomy was used on a series of resectable cancer pts
• 5 year survival = 54%• Local recurrence rate <8%
*68% major morbidity
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Benefit of Laparoscopy / Thoracoscopy
• General– Less pain– Shorter LOS/recovery– Better view
• Benign disease– Increasing volumes of end stage disease– Increasing comfort and reliance on MI
approaches– Lower morbidity / mortality
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Benefit of Laparoscopy / Thoracoscopy
Cancer• Best staging• Better residual QOL• Less frightening to patient and
their physicians• Earlier start to adjuvant therapy
and nutrition• Decreased immunosuppression
– Improved cure rates
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Staging / Determining Resectability:
• Laparoscopic/ thoracoscopic staging is accurate– 94% correlation with operative pathology*
• It is the best method, short of laparotomy, to determine resectability– 30% (6/20) positive nodes in imaging negative
patients*
* Krasna; 1995, 1998.
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Transhiatal Esophagectomy
• No need to reposition• Easier anesthesia• Faster?
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Ports
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Mediastinal Dissection
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Antireflux Mechanism
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Postoperative Care:
• To surgery floor• Gastrografin swallow
POD 2• Tube feeds POD2• D/C abd drain POD3• Pureed diet POD 3• Remove neck drain
when goes home
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Review of outcomes for Minimally Invasive osophagectomy
This study evaluated 104 MIS for malignant and benign esophageal diseases between 1998 – 2007
• 3 patients required conversion to laparotomy, median ICU & hospital stays were 2 & 8 days respectively.• Major complications in 12.5% pts. And minor
complications in 15.4%pts.• Incidence of leak was 9.6% and anastomotic
stricture was 26%. • 30 day mortality was 1.9% and in hospital mortality
2.9% Nguyen 2008
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Endoscopic therapies in T1 oesphageal cancers
• Osophagectomy is the standard treatment for T1 oesophageal cancers with good long term results• Many patients with T1 OC have several risk factors
that preclude treatment with endoscopic therapy• Many prospective studies needed to evaluate
endoscopic therapies until then esophagectomy should remain the standard treatment in patients with T1 EC.
Pennathur A 2009
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Open versus minimally invasive esophagectomy: a single-center case
controlled study
• Case controlled pair-matched study conducted comparing 62 patients who had undergone either minimally invasive (MIE) or open esophagectomy (OE) between 2004 and 2007• Surgical morbidity, transfusion rate and the rate
of post operative respiratory complications were significantly lower in the MIE group• The ICU and hospital stay were also
significantly lower in the MIE group.
Schoppmann SF 2010
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Conclusion:• Open esophagectomy with en bloc lymphadnectomy may
provide the best surgical cure rate for resectable esophageal cancer
• This can be replicated by the thoracoscopic / laparoscopic approach
• Laparoscopic esophagectomy offers theoretical potential for improved outcomes, possibly even improved survival for esophageal cancer patients and is an excellent technique for benign disease
• Currently, the technical difficulty of laparoscopic esophagectomy make it unlikely to be widely applied outside of regional laparoscopic referral centers.